Provider Demographics
NPI:1124012422
Name:GATEWAY MEDICAL GROUP LC
Entity type:Organization
Organization Name:GATEWAY MEDICAL GROUP LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-467-7084
Mailing Address - Street 1:312 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972-2565
Mailing Address - Country:US
Mailing Address - Phone:863-467-7084
Mailing Address - Fax:863-467-6833
Practice Address - Street 1:111 NE 19TH DR
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-1933
Practice Address - Country:US
Practice Address - Phone:863-357-1068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071118207R00000X
FLME0077602207R00000X
FLME0071683207R00000X
FLME0080601208800000X
FLME0021272208600000X
FLME00694652084N0400X
FLME0060312208000000X
FLME0060313207ZP0105X
FLME0021723207V00000X
FLME0057971207RP1001X
FLME0066502207RG0100X
FLME0043238207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0134Medicare ID - Type UnspecifiedGROUP NUMBER
FL12910Medicare ID - Type UnspecifiedLABORATORY PROVIDER NUMBE